Provider Demographics
NPI:1053651307
Name:MULLACKAL, NEISHE
Entity Type:Individual
Prefix:
First Name:NEISHE
Middle Name:
Last Name:MULLACKAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 47TH AVE
Mailing Address - Street 2:2120 D
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3013
Mailing Address - Country:US
Mailing Address - Phone:718-593-4121
Mailing Address - Fax:
Practice Address - Street 1:3100 47TH AVE
Practice Address - Street 2:2120 D
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-3013
Practice Address - Country:US
Practice Address - Phone:718-593-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program